I'm Taking a Poll

  1. I would like to know how many units out there are following the VAP bundle to the letter with their open-sternum post-op cardiac patients. By this I'm specifically looking at elevating the head of the bed and angle of torso to at least 30 degrees. If you're doing this, what kinds of cardiovascular and hemodynamic concerns are you seeing? If you aren't doing this, what are the reasons and are you seeing VAP in these kiddies?

    Our NICU uses either isolettes or Ohio overbed warmer units for all their babies. It's impossible to have the head of the bed and angle of torso at greater than about fifteen degrees, yet their babies don't seem to develop VAP. In our PICU we have no choice but to elevate them so that they're cantilevered on a pile of rolled up linen, unless we can get an order to nurse them at a lesser angle... regardless of their post-op status. Diaper changes are a two or three person job, even on the tiniest of babies, because our medical director insists that the only time the HOB can be lowered is for xrays, and sometimes not even then. My mind quails from the thought of the tip of that mediastinal chest tube flailing around inside the open chest... So I appeal to my colleagues everywhere for your experience.
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    About NotReady4PrimeTime, RN Senior Moderator

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  3. by   AliRae
    I wish I had an answer for you on that one, but I don't. We don't actually use follow the VAP bundle protocols. I'm not sure why we're backwards in this, but we don't. And we're a new cardiac program, so we've only had one open chest up until now. And we were all so scared of it, there's no WAY that bed was going up.

    Sorry! That was less than helpful...
  4. by   NotReady4PrimeTime
    No worries, Ali-Rae. We seem to have at least one open chest in the unit all the time... and they're really not that scary when you've seen a few. If the skin's closed, it's usually all good. (We had one baby a while back who didn't tolerate even the skin closed... Freaky to look at the Ioban and see the heart beating away underneath it!) We do about a dozen cardiac surgeries a week, not counting the in-unit chest closures and the kids we send from our unit and get back later. We had a run on Norwoods recently with four in eight days. Must be something in the water! On February 26th, the gang did three sternal closures one right after the other like an assembly line.

    But back to the VAP thing. It bothers me that our unit has selected which components of the bundle to incorporate. Some they've just looked at and said, "We're NOT doing that!!" For example, oral ETTS are associated with a significant decrease in the incidence of VAP, but virtually none of our patients will be orally intubated unless we get them that way and they're going to be extubated soon. With the HOB business, the kids are more restless and need bathtubs-full of sedation... and boy do we give it to them. I had a 10.5 kg baby recently who was getting more than 3 mg of morphine an hour as an infusion, and 8 mg of Versed an hour by infusion, PLUS phenobarb 40 mg q 6 hours, PLUS chloral hydrate 200 mg q 3 hours PLUS 100 mcg fentanyl pre-handling... They aren't allowed to move so much as an eyelash and they can't cough or breathe spontaneously. Until we're ready to extubate, then they go cold turkey for several hours until they're bouncing off the walls, then we start them on a methadone program. I hate that! Oh, and lest we forget, we use the same suction tubing and canister for all suctioning requirements. EWWWW! So I'm very interested in hearing what other units out there are doing in this respect, and how their results compare with ours.
  5. by   km5v6r
    Sorry I can't help with the heart surgery aspect as we don't do any heart's. We do the major bowel and liver transplants. Some of our kids will be on the vent for months; one for neary a year before finally trached. Rarely will our docs nasally intubate a kid. We also do alot of Nimbex or Vecuronium if the kids are on the HFOV or moving to much. Ativan and Methadone are started early on in the process; as soon as oral meds can be given through the NGT; well before plans to extubate. If they can't be given per NGT or if the absorbtion is questionable we will give IV Ativan and Morphine on a scheduled bases. This is in addition to the continous Versed and Fentanyl gtts. When it comes time to extubate the gtts are turned off but the scheduled Ativan and Methadone continue. The docs are very good about making sure we have adequate sedation, even at extubation.

    Just curious as to why the preference for nasal intubation? One of our intensivist prefers the nasal intubation and will occasionally change a tube placement but it is rare. This docs also works at the Children's hospital in town that does all of the cardiac surgery.
  6. by   NotReady4PrimeTime
    Nasal tubes are more secure because there's more of the tube in the pharynx and trachea, the curve at the nasopharynx is much more acute so there's less tube movement and the naris is a nice, tight little space to stabilize everything with. There's supposedly better tube tolerance because of the decreased tube movement, so they aren't gagging and chewing as much. But, and it's a big but... every single kid with a nasal tube will have raging sinusitis within a couple of days, with purulent postnasal drip into that lovely pool of slime at the glottis that gets sucked down into the terminal bronchioles with every cough.

    The unit I worked in before this one almost never had nasal tubes and the incidence of VAP there was very low, even with the HOB at only 10 to 20 degrees. They also had separate suction canisters for ETT suction and all other suction needs, so the risk of cross-contamination is lower.
  7. by   km5v6r
    Interesting. The rational behind nasal intubation makes sense but the sinusitis would be a major deterent. We rarely have an incident of VAP. Many times our kids do have an NGT in one nares and an NJT in the other. These tubes are usually place during OR with order to not touch the tube post op. These kids also have an amazing tolerance for the tube. Rarely do we have one chewing or gagging on the tube. I have watched kids sitting up or propped up in a boppy in the bed playing around the vent tubing.
  8. by   NotReady4PrimeTime
    You would never see anything like that in our unit unless the kid's an adolescent who can be trusted to leave the tube alone. Our physicians are so inconsistent, it's almost a joke. They don't want the kids to move a hair while they're tubed, especially with an open sternum or abdominal fascia, but we have a couple who require them to be sitting up watching TV before they'll extubate them. So we'll take them from morphine at 300 mcg/kg/hr and midazolam 5 mcg/kg/min to NOTHING!!! then anaesthetize them with propofol so that the doc can be the one to decide when the tube comes out.

    Our management has also gotten almost insulting over VAP precautions. They had a bunch of laminated signs made up to tape to the side rails of the beds to indicate that the ventilator circuit is running along side of it. One nurse asked what was next, signs saying "Caution, Foley between legs"? We also have a tool at each bedside to measure the angle of the torso relative to the mattress and are expected to measure and document the AOT on the flowsheet every hour. This is in addition to our shift documentation on our PICU assessment forms, our QI forms, our Braden-Q scores, our microbiology log, our signature log, our MARs, our Patient Care Record (narrative), our withdrawal scoring tool, our neurovitals sheet, our neurovascular sheet, the patient problem list, our central line insertion checklist, our wound assessment form... our stack of papers is about 1/4 inch thick, and we're still using pen and paper! Then of course, every weekday our QI coordinator makes a tour of the unit with her own tools and documents, does her own measurements, reminds us of all the computer-based learning modules we have to complete and checks to see that we've all obediently filled out all our forms. Never mind that you might have been putting in lines, pushing fluid and mixing pressors for hours, the paperwork has to be done when she comes around. Sigh. I'm feeling a trifle burnt out...
  9. by   km5v6r
    Good Grief!!! Makes me even happier to be where I'm at. We are slowly converting over to computer charting and things like the Braden are already on the computer. We just don't have enough computer terminals between the med students, nursing students and parents. The amount of documentation we have to do to restrain even an intubated kid is horrible. Many of our kids are flat post-op also. Especially if they are on the HFOV and CRRT.

    I understand the burn out. We were so slammed with trauma this weekend that the PICU ended up with an adult closed head injury. He was admitted Friday night and Monday Trauma decides he needs to be transfered to the AICU. Family doesn't want him to transfer, I feel he is to unstable to transfer but transfer he must. I am hanging Dopamine on him, Neo is max'd, ICP climbing, CPP dropping, pupils unequal and fixed, family crying, and my manager stops in and tells me I have to leave work. What the HE... It seems last winter I did BLS through my previous employer through the American Red Cross. The ARC card is only for 1 yr. For the past 25 yrs I have done my BLS through the American Heart Association and the card is good for 2 yrs. My ARC card expired 2 weeks ago and I can't work until I retake the full class on Thursday. I so wanted to do my CPR demo on the trauma resident. The pt was expected to pass in the next 24-48 hours. Would it have been so difficult to allow the family to stay with the unit and staff they were familiar with? Would it have been to difficult for my manager to wait until after I was through with one crisis before dropping another bomb (suspension) on me? At least I only missed one shift today and the weather was beautiful. 80 degress today. Hard to believe we had 12+ inches of snow less then 2 weeks ago.
  10. by   NotReady4PrimeTime
    I feel for you. I ran into something like that when I started here. The CPR thing I mean... I ended up having to take it at the University and paid $160 bucks for it. Now though, we do an annual recertification of all our specialized skills timed to ensure our CPR doesn't lapse. This year we're getting ripped off, though. With the new guidelines for BCLS and all its cousins, the CPR content is going to take up a larger part of our scheduled time than usual so we won't be paid 4 hours for the prep/review time, which has typically really taken me about 8 hours to do. I'm annoyed.

    As for the situation with the patient, that's really nasty! We had to admit an adult with congenital heart disease after a cath that went horribly wrong because the adult ICU didn't have a bed for him on a Friday afternoon... he wasn't supposed to need one... But we ended up keeping him for four months. The CV surgeon pleaded for us to keep his patient because he trusted us to provide the kind of care he needed more than he did the adult side. It's what we do and we're darned good at it, and I think we gave this man the best outcome he could have had. He was finally transferred back to hospital closer to his home to finish his convalescence then he went home and is doing well.

    12+ inches of snow? I'll trade you our remaining 2 and a 1/2 feet!! Oh look, there's more coming down! Oh, and 80 is about as warm as it EVER gets here, so I don't wanna know!
  11. by   climberrn
    We kept the HOB at 30 degrees, had different canisters for oral vs. ett suctioning but we were allowed to lower the bed for cares (diaper changes, etc.). We also used a paralytic as long at their chest was open...along with tons of sedation. Our VAP rate did decrease when we started increasing the HOB angle.
  12. by   NotReady4PrimeTime
    It would be so nice to have the option of a neuromuscular blockade for our open sternum patients, but considering that we usually have to chase somebody and beg for one when we're cooling a kid to popsicle range, that's not usually on the table. More's the pity.
  13. by   km5v6r
    Almost 90 on Tuesday and snow today. Typical. This type of weather in March though is scary. Probably means the summer will be hiddously hot and long.

    The CPR class was short and good. I am actually glad to take the class with all the changes being implemented. I am sure in a real code I will still do a head tilt-neck lift and find hand placement by finding the zyphoid process.
  14. by   NotReady4PrimeTime
    Perhaps I shouldn't admit this in public but I've always landmarked by eye-balling the sternum midline between the nipples. I only used the xiphoid landmark in the class...

    41 degrees here today and sunny. Lots of melting, but still tons more to go. Potholes are unreal! The roads look like a moonscape.